The Village Referral to Shelter Services

The Village Referral to Shelter Services
If you would like someone to be considered for our services, please go through the referral and approval process. We understand that the need is high and resources are limited. Out of county/state residents or drop-offs from other agencies will not be accepted without prior approval.

Please complete the form and referrals will be evaluated as our programs have availability. Any Douglas County resident may seek shelter in our Night-by-Night Program (7pm-8am) as long as they are able to meet the LCS Expectations while we wait for availability in other programs.

We are unable to serve individuals who cannot meet their own basic care needs such as performing their own personal hygiene, toileting unassisted, eating unassisted, dressing, undressing, ambulating/navigating the building, and surrounding area unassisted.

Thank you.
1. Your Name

First NameLast Name
Email
example@example.com
Agency and Title
2. Referral Name

First NameLast Name
Contact Information

Email (example@example.com)Phone Number
Date of Birth

MonthDayYear
Must be 18 or older.
Marital Status

SingleMarried (applying with spouse)Married (applying separately)
Spouse Name if Applicable (enter NA in both fields if not)

First NameLast Name
3. Does the individual have a criminal history? Particularly violent criminal charges? When? Please explain:
4. Is the individual a Douglas County resident?

YesNoNot Sure
5. If they are not a Douglas County resident what connections supports or resources do they have available to them in Douglas County? (enter NA if not applicable)
6. Is the individual currently unsheltered or staying in a place not intended for human habitation?

YesNoNot Sure
7. Has the individual been entered into Clarity?

YesNoNot Sure
8. Does the individual have a completed CES Assessment?

YesNoNot Sure
If Yes, what was their score and when was the assessment conducted? (Please put "N/A" if not applicable of "Not Sure" if unknown)
9. Does the individual meet the definition of chronically homeless? (Chronic homelessness is used to describe people who have experienced homelessness for at least a year — or repeatedly — while struggling with a disabling condition such as a serious mental illness, substance use disorder, or physical disability.)

YesNoNot Sure
10. Does the individual meet any of the following criteria?

VeteranSenior (55 or over)Documented DisabilityFleeing or Survivor of Domestic ViolenceOther
11. Please provide details on the selected criteria above and/or define other if selected:
12. Village guests are required to participate in wrap-around services, including case management. What agencies is the referral working with?

Bert Nash Community Mental Health CenterCity Team (Lawrence Homeless Solutions)DCCCADCSO ReentryFamily PromiseHaskell Indian Health CenterHeartland Community Health CenterLawrence Community ShelterLawrence Humane SocietyRed CrossRADACVeterans AffairsThe WillowWork for SuccessOther
Please define "Other" if applicable and add case manager's name and contact information:
13. What agencies is the referral interested in working with? Referrals are encourage to start services while on the wait list.

Bert Nash Community Mental Health CenterCity Team (Lawrence Homeless Solutions)DCCCADCSO ReentryFamily PromiseHaskell Indian Health CenterHeartland Community Health CenterLawrence Community ShelterLawrence Humane SocietyRed CrossRADACVeterans AffairsThe WillowWork for SuccessOther
Please define "Other" of applicable. Enter "NA" if not.
14. Does the referral have a pet?

YesNoDocumented Certified Service Animal
The Village only allows documented certified service animals on site. Referrals are required to make arrangements for the pet to be fostered or boarded before entering the Village. If you need assistance, please contact Lawrence Humane Society Pet Resource Center for more information as soon as possible.
15. Is there anything else you would like for us to know or consider?
Please also fill out and upload the linked forms in the upload section below:

3rd Party Homeless Verification Referral - https://tinyurl.com/3rdpartyref

Community Partner ROI - https://tinyurl.com/compartroi
File Upload

Cancelof
Thank you for your referral.
Should be Empty: